Reply

Abstract

Alfred Habeeb Professor and Chairman of Anesthesiology, Professor of Obstetrics and Gynecology, University of Alabama at Birmingham School of Medicine, 619 South 19th Street, Birmingham, Alabama 35233–6810.In Reply:—I appreciate Gould's interest in our two studies, [1,2] Using the “catastrophe theory,” Gould observed that a substantial increase in the use of epidural analgesia was associated with a slight increase in the cesarean section rate in his hospital. Others have used similar methodology to demonstrate that the introduction of an epidural analgesia service did not result in an increased cesarean section rate in their hospital. [3] Likewise, others have observed that good obstetric management (e.g., active management of labor, peer review of cesarean section rates for individual physicians, trial of labor after previous cesarean section) results in a decreased cesarean section rate, despite the increased utilization of epidural analgesia. [4–6].Gould did not acknowledge that our technique for epidural analgesia was identical to that used by Thorp et al. [7] Nonetheless, the cesarean section rate for patients in spontaneous labor in our study [2] was substantially less than the cesarean section rate for similar women who received epidural analgesia in the study performed by Thorp et al. [7].I agree with Gould that epidural analgesia is not a generic procedure. It is possible that, under certain circumstances, epidural analgesia may increase the risk for cesarean section in selected patients. The study by Thorp et al. [7] was limited by several factors. First, the authors enrolled a small number of patients. How many times did they “peek” at their data during the performance of the study? Second, Thorp et al. [7] included indigent patients only. Given the strength of Thorp's convictions regarding the effect of epidural analgesia on the cesarean section rate, it is curious that he and his colleagues did not enroll private patients in their study. Third, Thorp et al. [7] did not clearly identify the method of randomization. Specifically, it is unclear that the sealed envelopes were sequentially numbered. Fourth, the authors of the study—who obviously were not blinded to the group assignment—assumed responsibility for decisions regarding the method of delivery.Anesthesiologists should carefully evaluate the potential effects of epidural analgesia on the progress of labor and method of delivery. We should identify those techniques that provide the most effective analgesia with the least adverse effect on the progress of labor and method of delivery. Unfortunately, Thorp et al. [7] have substantially overestimated the potential contribution of epidural analgesia to the “cesarean section epidemic.”[8] As a result, they have performed a disservice to current and future pregnant women. Their results do not reflect outcome at a variety of other medical centers in the United States and abroad. Thorp et al. [7] have caused some women to experience an inordinate fear of epidural analgesia. Further, their study may encourage third-party payers to deny reimbursement for labor analgesia, in the absence of a so-called “medical indication.”*Larson DD: The effect of initiating an obstetric anesthesiology service on rate of cesarean section and rate of forceps delivery (abstract). Proceedings of the Annual Meeting of the Society for Obstetric Anesthesia and Perinatology, 1992.Let us not forget the joint statement of the American Society of Anesthesiologists and the American College of Obstetricians and Gynecologists:“There is no other circumstance where it is considered acceptable for a person to experience severe pain, amenable to safe intervention, while under a physician's care. Maternal request is a sufficient justification for pain relief during labor.”David H. Chestnut, M.D., Alfred Habeeb Professor and Chairman of Anesthesiology; Professor of Obstetrics and Gynecology; University of Alabama at Birmingham School of Medicine, 619 South 19th Street, Birmingham, Alabama 35233–6810.(Accepted for publication October 4, 1994.)